17735 Chappel Ave. Lansing, IL 60438
P: 800-252-ROSE or (708) 895-2423
F: (708) 895-2494

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Drivers Application for Employment
Company: ROSE CARTAGE SERVICE, INC.
Address: 17735 Chappel AVENUE
City: LANSING         State: IL         Zip Code: 60438
 
In compliance with Federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
Date of application:
Position(s) Applied for:
Last Name:
First Name:
Middle Name:
Social Security No:
Address:
City:
State:
Zip Code:
Phone:
ADDRESS FOR PAST THREE YEARS
Address:
City:
State:
Zip Code:
How Long?
Years:  Months: 
 
Address:
City:
State:
Zip Code:
How Long?
Years:  Months: 
 
Do you have the legal right to work in the United States?
Date of Birth:(Required for Truck Driver)
      
Can you provide proof of age?
Yes    No
Have you worked for this company before?
Yes    No
Where?
Dates:
From:   To:
Rate of Pay:
Position:
Reason for leaving?
Are you now employed? Yes    No
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected:
EMERGENCY CONTACT NAME & TELEPHONE NUMBER:   
Is there any reason you might be unable to perform the functions of the jobs for which you have applied (as describe in the attached job description):
If yes, explain if you wish:
Employment History
All driver applications to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.

Application to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.
(NOTE : List employers in reverse order starting with the most recent. Add another sheet as necessary)
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
EMPLOYER
DATE
From:
To:
Position Held:
Name:
Address:
City:
State:
Zip Code:
Contact Person:
Salary/Wage:
Phone Number:
Reason for leaving:
Includes vehicle having a GVWR of 26,001 lbs. or more, vehicle designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORDS FOR PAST 3 YEARS OR MORE
DATES NATURE OF ACCIDENT
(HEAD - ON REAR -END UPSET ETC)		 FATALITIES INJURIES
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
LOCATION DATE CHARGE PENALTY
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED:    1   2   3   4   5   6   7   8
HIGH SCHOOL:    1   2  3   4
COLEGE:    1   2   3   4
LAST SCHOOL ATTENDED:   
EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVER LICENSES

 LICENSE NO. STATE TYPE EXPIRATION DATE
  1. Have you ever been denied a license, permit or privilege to operate a motor vehicle?    YES   NO
  2. Has any license, permit or privilege ever been suspended or revoked?    YES   NO

IF THE ANSWER TO EITHER A OR B IS YES , PLEASE GIVE DETAILS BELOW:

DRIVING LICENSE
CLASS EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC)
DATES
FROM TO
APPROX NO. OF MILES (MILES)
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILER
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, Understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

 
Applicant's Signature Date  
I authorize Rose Cartage Service, Inc. to release all past employment records regarding previous employment.
 
To all my previous employers:
Please accept this online form document as an original authorization for release of all employment records including reason for termination or resignation, drug and alcohol test results, accident history and driving records.
Signature   Date
 
Last Name   First Name   Middle Name
   
Drivers License Number   ST
 
      

 
 
Rose Cartage Service, Inc.
17735 Chappel Avenue
Lansing, IL 60438
708.895.2423
Fax: 708.895.2494


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